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Calomino N, Carbone L, Kelmendi E, Piccioni SA, Poto GE, Bagnacci G, Resca L, Guarracino A, Tripodi S, Barbato B, Brillanti S, Roviello F, Adani GL, Marrelli D. Western Experience of Hepatolithiasis: Clinical Insights from a Case Series in a Tertiary Center. MEDICINA (KAUNAS, LITHUANIA) 2025; 61:860. [PMID: 40428818 PMCID: PMC12113244 DOI: 10.3390/medicina61050860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2025] [Revised: 05/04/2025] [Accepted: 05/06/2025] [Indexed: 05/29/2025]
Abstract
Background and Objectives: Hepatolithiasis (HL), or intrahepatic bile duct stone disease, shows regional variation and is a rare condition in Western countries. While cases from East Asia are often linked to chronic biliary infections and brown pigment stones, Western HL more frequently involves cholesterol or black pigment stones, typically in the context of prior cholecystectomy, biliary interventions, or congenital anomalies. The disease is generally associated with significant morbidity, including recurrent cholangitis, biliary strictures, and risk of cholangiocarcinoma. This study aimed to characterize HL disease in an Italian case series. Materials and Methods: We retrospectively reviewed 1450 patients with biliary stone disease treated between 2010 and 2024. HL was diagnosed in 14 patients (0.96%). Clinical records, imaging (ultrasound, CT, magnetic resonance cholangiopancreatography-MRCP, cholangiography), bile cultures, and stone composition (categorized as cholesterol, brown pigment, black pigment, or mixed using FTIR/XRD) were analyzed. Results: Among the 14 patients (mean age: 60.1 years; 64.3% female), 71.4% presented with recurrent cholangitis, while 28.6% were asymptomatic. Stones were left-sided in 57.1%, right-sided in 21.4%, and bilateral in 21.4%. Stone composition was cholesterol/mixed in 50%, brown pigment in 35.7%, and black pigment in 14.3%. Risk factors for bile stasis were present in 71.4% of cases. Bile cultures (available in nine cases) were positive in 77.8%. MRCP was highly effective for diagnosis. Hepatectomy achieved complete resolution in 35.7% of patients with unilobar disease; endoscopic/percutaneous therapy had a 44.4% recurrence rate. Interestingly, no cholangiocarcinoma was observed over a median follow-up of 4.8 years. Conclusions: Western HL is a rare, heterogeneous disease with distinct features. Cholesterol-predominant, infection-negative cases suggest a metabolic or surgical etiology. Hepatectomy offers durable outcomes in unilobar disease. Advanced imaging (MRCP, cholangioscopy) and personalized strategies are key to effective management.
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Affiliation(s)
- Natale Calomino
- Unit of Kidney Transplant, Department of Surgery, Azienda Universitaria Ospedaliera Senese, 53100 Siena, Italy;
| | - Ludovico Carbone
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
| | - Engjell Kelmendi
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
| | - Stefania Angela Piccioni
- Unit of Surgical Oncology, Department of Oncology, Azienda Universitaria Ospedaliera Senese, 53100 Siena, Italy;
| | - Gianmario Edoardo Poto
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
| | - Giulio Bagnacci
- Unit of Diagnostic Imaging, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy;
| | - Luca Resca
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
| | - Annalisa Guarracino
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
| | - Sergio Tripodi
- Section of Pathology, Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy; (S.T.); (B.B.)
| | - Bina Barbato
- Section of Pathology, Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy; (S.T.); (B.B.)
| | - Stefano Brillanti
- Unit of Gastroenterology, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy;
| | - Franco Roviello
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
- Unit of Surgical Oncology, Department of Oncology, Azienda Universitaria Ospedaliera Senese, 53100 Siena, Italy;
| | - Gian Luigi Adani
- Unit of Kidney Transplant, Department of Surgery, Azienda Universitaria Ospedaliera Senese, 53100 Siena, Italy;
| | - Daniele Marrelli
- Unit of General Surgery, Department of Medicine Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (L.C.); (E.K.); (G.E.P.); (L.R.); (A.G.); (F.R.); (D.M.)
- Unit of Surgical Oncology, Department of Oncology, Azienda Universitaria Ospedaliera Senese, 53100 Siena, Italy;
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Koo JGA, Tham HY, Toh EQ, Chia C, Thien A, Shelat VG. Mirizzi Syndrome-The Past, Present, and Future. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:12. [PMID: 38276046 PMCID: PMC10818783 DOI: 10.3390/medicina60010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024]
Abstract
Mirizzi syndrome is a complication of gallstone disease caused by an impacted gallstone in the infundibulum of the gallbladder or within the cystic duct, causing chronic inflammation and extrinsic compression of the common hepatic duct or common bile duct. Eventually, mucosal ulceration occurs and progresses to cholecystobiliary fistulation. Numerous systems exist to classify Mirizzi syndrome, with the Csendes classification widely adopted. It describes five types of Mirizzi syndrome according to the presence of a cholecystobiliary fistula and its corresponding severity, and whether a cholecystoenteric fistula is present. The clinical presentation of Mirizzi syndrome is non-specific, and patients typically have a longstanding history of gallstones. It commonly presents with obstructive jaundice, and can mimic gallbladder, biliary, or pancreatic malignancy. Achieving a preoperative diagnosis guides surgical planning and improves treatment outcomes. However, a significant proportion of cases of Mirizzi syndrome are diagnosed intraoperatively, and the presence of dense adhesions and distorted anatomy at Calot's triangle increases the risk of bile duct injury. Cholecystectomy remains the mainstay of treatment for Mirizzi syndrome, and laparoscopic cholecystectomy is increasingly becoming a viable option, especially for less severe stages of cholecystobiliary fistula. Subtotal cholecystectomy is feasible if total cholecystectomy cannot be performed safely. Additional procedures may be required, such as common bile duct exploration, choledochoplasty, and bilioenteric anastomosis. Conclusions: There is currently no consensus for the management of Mirizzi syndrome, as the management options depend on the extent of surgical pathology and availability of surgical expertise. Multidisciplinary collaboration is important to achieve diagnostic accuracy and guide treatment planning to ensure good clinical outcomes.
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Affiliation(s)
- Jonathan G. A. Koo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; (J.G.A.K.); (H.Y.T.)
| | - Hui Yu Tham
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; (J.G.A.K.); (H.Y.T.)
| | - En Qi Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore;
| | - Christopher Chia
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore 308433, Singapore;
| | - Amy Thien
- Department of General Surgery, Raja Isteri Pengiran Anak Saleha Hospital, Bandar Seri Begawan BA 1710, Brunei;
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; (J.G.A.K.); (H.Y.T.)
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore;
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Lai W, Yang J, Xu N, Chen JH, Yang C, Yao HH. Surgical strategies for Mirizzi syndrome: A ten-year single center experience. World J Gastrointest Surg 2022; 14:107-119. [PMID: 35317542 PMCID: PMC8908338 DOI: 10.4240/wjgs.v14.i2.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/13/2021] [Accepted: 01/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mirizzi syndrome (MS) remains a challenging biliary disease, and its low rate of preoperative diagnosis should be resolved. Moreover, technological advances have not resulted in decisive improvements in the surgical treatment of MS. Complex bile duct lesions due to MS make surgery difficult, especially when the laparoscopic approach is adopted. The safety and long-term effect of MS treatment need to be guaranteed in terms of preoperative diagnosis and surgical strategy.
AIM To analyze preoperative diagnostic methods and the safety, effectiveness, prognosis and related factors of surgical strategies for different types of MS.
METHODS The clinical data of MS patients who received surgical treatment from January 1, 2010 to December 31, 2020 were retrospectively reviewed. Patients with malignancies, choledochojejunal fistula, lack of data and lost to follow-up were excluded. According to preoperative imaging examination records and documented intraoperative findings, the clinical types of MS were determined using the Csendes classification. The safety, effectiveness and long-term prognosis of surgical treatment in different types of MS, and their interactions with the clinical characteristics of patients were summarized.
RESULTS Sixty-six patients with MS were included (34 males and 32 females). Magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) showed specific imaging features of MS in 58 cases (87.9%), which was superior to ultrasound scan (USS) in the diagnosis of MS and more sensitive to subtle biliary lesions than USS. The overall laparoscopic surgery completion rate was 53.03% (35/66), where the completion rates of MS type I, II and III were 69.05% (29/42), 42.86% (6/14) and zero (0/10), respectively. Thirty-one patients (46.97%) underwent laparotomy or conversion to laparotomy including 11 cases of iatrogenic bile duct injury which occurred in type I patients, and 25 of these patients underwent bile duct exploration, repair and T-tube drainage. In addition, 25 patients underwent intraoperative choledochoscopy and T-tube cholangiography. Overall, 21 cases (31.8%) were repaired by simple suturing, and 14 cases (21.2%) were repaired using the remaining gallbladder wall patch in the subtotal cholecystectomy. The ascendant of the Csendes classification types led to an increase in surgical complexity reflected by increased operation time, bleeding volume and cost. Gender, acute abdominal pain and measurable stone size had no effect on Csendes type of MS or final surgical approach. Age had no effect on the classification of MS, but it influenced the final surgical approach, hospital stay and cost. A total of 66 patients obtained a relatively high preoperative diagnostic rate and underwent surgery safely without serious complications, and no mortality was observed during the follow-up period of 36.5 ± 26.5 mo (range 13-76, median 22 mo).
CONCLUSION MRI/MRCP can improve the preoperative diagnosis of MS. The Csendes classification can reflect the difficulty of treatment. The surgical strategies including laparoscopic surgery for MS should be formulated based on full evaluation and selection.
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Affiliation(s)
- Wei Lai
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
| | - Jie Yang
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
| | - Nan Xu
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
| | - Jun-Hua Chen
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
| | - Chen Yang
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
| | - Hui-Hua Yao
- Department of Hepatobiliary-Pancreatic-Splenic Surgery, Chengdu First People’s Hospital (Chengdu Integrated TCM & Western Medicine Hospital), Chengdu 610044, Sichuan Province, China
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Shafiq S, Patil M, Philip M. Mirizzi syndrome: A retrospective analysis of 84 patients from a single center. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii210018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Syed Shafiq
- Department of Gastroenterology, St. John’s Medical College Hospital, Bengaluru, India
| | - Mallikarjun Patil
- Department of Gastroenterology, St. John’s Medical College Hospital, Bengaluru, India
| | - Mathew Philip
- Department of Gastroenterology, Lisie Hospital, Kochi, India
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Sato H, Hiraki M, Miyoshi A, Ikeda S, Koga H, Kitahara K. The strategy for Mirizzi syndrome type II with laparoscopic surgery: A case report. Int J Surg Case Rep 2020; 77:673-676. [PMID: 33395871 PMCID: PMC7710499 DOI: 10.1016/j.ijscr.2020.11.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Mirizzi syndrome is an unusual condition involving gallstones. Laparotomy is recommended for the treatment of Mirizzi syndrome type II due to the risk of biliary duct injury. We herein report tips for performing laparoscopic surgery for Mirizzi syndrome type II as a treatment option. PRESENTATION OF CASE A 72-year-old woman was admitted to our hospital due to abdominal pain and a fever. The diagnosis of Mirrizi syndrome type II was made. Therefore, an endoscopic retrograde biliary drainage tube was placed, and laparoscopic surgery was performed. During the operation, the gallbladder wall was excised at the Hartmann's pouch, and a gallstone was extracted. A fistula between the gallbladder and bile duct was confirmed, and the diagnosis of Mirizzi syndrome type II was made. Partial resection of the gallbladder was performed, and the neck of the gallbladder was sutured. The postoperative course was uneventful. DISCUSSION The preoperative diagnosis is important for Mirizzi syndrome, and the combination of various modalities, including endoscopic retrograde cholangiopancreatography, can increase the diagnostic rate. It is often difficult to recognize the anatomy during surgery for Mirizzi syndrome due to severe inflammation. Therefore, it is best to dissect the gallbladder from the bottom, perform excision at the Hartmann's pouch, remove the gallstone and suture the gallbladder wall. Replacement of the biliary tube can aid in recognizing the anatomy and bile duct. CONCLUSION Laparoscopic surgery for Mirizzi syndrome is a viable treatment option following an accurate preoperative diagnosis and the recognition of the anatomy during the operation.
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Affiliation(s)
- Hirofumi Sato
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan
| | - Masatsugu Hiraki
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan.
| | - Atsushi Miyoshi
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan
| | - Shota Ikeda
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan
| | - Hiroki Koga
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga City, Saga, 849-8571, Japan
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Payá-Llorente C, Vázquez-Tarragón A, Alberola-Soler A, Martínez-Pérez A, Martínez-López E, Santarrufina-Martínez S, Ortiz-Tarín I, Armañanzas-Villena E. Mirizzi syndrome: a new insight provided by a novel classification. Ann Hepatobiliary Pancreat Surg 2017; 21:67-75. [PMID: 28567449 PMCID: PMC5449366 DOI: 10.14701/ahbps.2017.21.2.67] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/19/2017] [Accepted: 01/21/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUNDS/AIMS Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis. The aim of this study is to evaluate our 15-year experience in this challenging entity and to propose a new classification for this disease. METHODS A retrospective study including patients diagnosed with Mirizzi syndrome and undergoing surgical procedures for Mirizzi syndrome between January 2000 and October 2015 was conducted. Data collected included clinical, surgical procedure, postoperative morbidity. Patients were evaluated according to the Csendes classification and the proposed system, in which patients were divided into three types and three subtypes. RESULTS 28 patients were included for analysis. They accounted as the 0.5% of a total of 4853 cholecystectomies performed in the study period. There were 21 women and 7 men. Initial laparotomic approach was performed in 12 patients and in 16 patients laparoscopic procedures were attempted. The procedure was completed in only 6 patients, 5 presenting type I and 1 type II Mirizzi syndrome. Mean postoperative stay was 15±9 days. Postoperative morbidity rate was 28%. Postoperative mortality was none. CONCLUSIONS Laparoscopic surgery for Mirizzi syndrome has been shown succesful only in early stages. A novel classification is proposed, based on the types of common bile duct injuries and in the presence cholecystoenteric fistula.
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Prada-Arias M, Vázquez-Castelo JL, Blanco-Lobato P, Gómez-Veiras J, Montero-Sánchez M, Vieito-Fuentes JM. Exceptional Mirizzi syndrome in a young child: A laparoscopic approach. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Beltrán MA. Mirizzi syndrome: History, current knowledge and proposal of a simplified classification. World J Gastroenterol 2012; 18:4639-50. [PMID: 23002333 PMCID: PMC3442202 DOI: 10.3748/wjg.v18.i34.4639] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/16/2012] [Accepted: 03/20/2012] [Indexed: 02/06/2023] Open
Abstract
Chronic complications of symptomatic gallstone disease, such as Mirizzi syndrome, are rare in Western developed countries with an incidence of less than 1% a year. The importance and implications of this condition are related to their associated and potentially serious surgical complications such as bile duct injury, and to its modern management when encountered during laparoscopic cholecystectomy. The pathophysiological process leading to the subtypes of Mirizzi syndrome has been explained by means of a pressure ulcer caused by an impacted gallstone at the gallbladder infundibulum, leading to an inflammatory response causing first external obstruction of the bile duct, and eventually eroding into the bile duct and evolving to a cholecystocholedochal or cholecystohepatic fistula. This article reviews the life of Pablo Luis Mirizzi, describes the earlier and later descriptions of Mirizzi syndrome, discusses the pathophysiological process leading to the development of these uncommon fistulas, reviews the current diagnostic modalities and surgical approaches and finally proposes a simplified classification for Mirizzi syndrome intended to standardize the reports on this condition and to eventually develop a consensual surgical approach to this unexpected and seriously dangerous condition.
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Casasanta M, Mello M, Aghazarian S, Zapas J. Cholecystenteric Fistula: The Spectrum of Disease and Treatment Modalities. Am Surg 2012. [DOI: 10.1177/000313481207800510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marc Casasanta
- Department of Surgery Union Memorial Hospital Baltimore, Maryland
| | - Matthew Mello
- Department of Surgery Union Memorial Hospital Baltimore, Maryland
| | | | - John Zapas
- Department of Surgery Union Memorial Hospital Baltimore, Maryland; and Division of Surgical Oncology The Franklin Square Hospital Center Baltimore, Maryland
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Benign biliary strictures: a current comprehensive clinical and imaging review. AJR Am J Roentgenol 2011; 197:W295-306. [PMID: 21785056 DOI: 10.2214/ajr.10.6002] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE There is a wide spectrum of nonneoplastic causes of biliary stricture that can pose a significant challenge to clinicians and radiologists. Imaging plays a key role in differentiating benign from malignant strictures, defining the extent, and directing the biopsy. We describe the salient clinical and imaging manifestations of benign biliary strictures that will help radiologists to accurately diagnose these entities. CONCLUSION Accurate diagnosis and management are based on correlating imaging findings with epidemiologic, clinical, and laboratory data. Cross-sectional imaging modalities permit precise localization of the site and length of the segment involved, thereby serving as a road map to surgery, and permit exclusion of underlying malignancy.
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Chatzoulis G, Kaltsas A, Danilidis L, Dimitriou J, Pachiadakis I. Mirizzi syndrome type IV associated with cholecystocolic fistula: a very rare condition--report of a case. BMC Surg 2007; 7:6. [PMID: 17531103 PMCID: PMC1892769 DOI: 10.1186/1471-2482-7-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 05/27/2007] [Indexed: 12/12/2022] Open
Abstract
Background Mirizzi syndrome is a rare complication of prolonged cholelithiasis with presence of large, impacted gallstone into the Hartman's pouch, causing chronic extrinsic compression of common bile duct (CBD). Fistula formation between the CBD and the gallbladder may represent an outcome of that condition. According to Mirizzi's classification and Csendes's subclassification, Mirizzi syndrome type IV represents the most uncommon type (4%). Spontaneous biliary-enteric fistulas have also been rarely reported (1.2–5%) in a large series of cholecystectomies. Cholecystocolic fistula is the most infrequent biliary enteric fistula, causing significant morbidity and representing a diagnostic challenge. Case presentation We describe a very rare, to our knowledge, combination of Mirizzi syndrome type IV and cholecystocolic fistula. A 52 year old male, presented to our clinic complaining of episodic diarrhea (monthly episodes lasting 16 days), high temperature (38°C–39°C), right upper quadrant pain without jaundice. The definitive diagnosis was made intraoperatively. Magnetic Resonance Imaging (MRI) and Endoscopic Retrograde Cholangiopancreatography (ERCP) demonstrated the presence of Mirizzi syndrome with cholecystocolic fistula formation. The patient was operated upon, and cholecystectomy, cholecystocolic fistula excision and Roux-en-Y biliary-enteric anastomosis were undertaken with excellent post-operative course. Conclusion Appropriate biliary tree imaging with ERCP and MRI/MRCP is essential for the diagnosis of Mirizzi syndrome and its complications. Cholecystectomy, fistula excision and biliary-enteric anastomosis with Roux-en-Y loop appears to be the most appropriate surgical intervention in order to avoid damage to Calot's triangle anatomic elements. Particularly in our case, ERCP was a valuable diagnostic tool that Mirizzi syndrome type IV and cholecystocolic fistula.
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Affiliation(s)
| | - Andreas Kaltsas
- Department of Surgery, 424 Military Hospital Thessaloniki, Greece
| | | | - John Dimitriou
- Department of Surgery, 424 Military Hospital Thessaloniki, Greece
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Abstract
Cholelithiasis and cholesterolosis associated with carcinoma in situ of the cystic duct epithelium was observed in a male patient. Ultrastructurally, small acini-like lined a thickened, reduplicated basal lamina encompassing a pleiomorphic population of cells, including typical cholecystocytes, a poorly differentiated type, and cells containing modified mucous vesicles with heterogeneous fatty deposits. Even though the etiology of this apparent neoplastic epithelium and of its thickened basal lamina is unclear, it is hypothesized to be the result of an altered control of cell adhesion mechanisms, resulting from a repeated renewal of the typical epithelium abraded by the passage of the stones and the biliary sludge, associated with inflammatory stimuli that accompany cholecystolithiasis. Based on recent studies, it is suggested that investigations of molecular markers in extrahepatobiliary tract lesions and retrospective studies of these archival tissues could clarify the association of these neoplastic changes with other hepato-biliary lesions.
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Affiliation(s)
- Jacques Gilloteaux
- Department of Surgery, Summa Health System, Summa Research Foundation, Akron, Ohio, USA.
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Wei Q, Shen LG, Zheng HM. Hand-assisted laparoscopic surgery for complex gallstone disease: A report of five cases. World J Gastroenterol 2005; 11:3311-4. [PMID: 15929191 PMCID: PMC4316072 DOI: 10.3748/wjg.v11.i21.3311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To describe the use of hand-assisted laparoscopic surg-ery (HALS) as an alternative to open conversion for complex gall-stone diseases, including Mirizzi syndrome (MS) and mimic MS.
METHODS: Five patients with MS and mimic MS of 232 consecutive patients undergoing laparoscopic cholecyst-ectomies were analyzed. HALS without a hand-port device was performed as an alternative to open conversion if the anatomy was still unclear after the neck of the gallbladder was reached.
RESULTS: HALS was performed on three patients with MS type I and 2 with mimic MS owing to an unclear or abnormal anatomy, or an unusual circumstance in which an impacted stone was squeezed out from the infundibulum or the aberrant cystic duct impossible with laparoscopic approach. The median operative time was 165 min (range, 115-190 min). The median hand-assisted time was 75 min (range, 65-100 min). The median postoperative stay was 4 d (range, 3-5 d). The postoperative course was uneventful, except for 1 patient complicated with a minor incision infection.
CONCLUSION: HALS for MS type I and mimic MS is safe and feasible. It simplifies laparoscopic procedure, and can be used as an alternative to open conversion for complex gallstone diseases.
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Affiliation(s)
- Qi Wei
- Department of General Surgery, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou 310016, Zhejiang Province, China.
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N/A, 沈 来, 郑 和. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:572-574. [DOI: 10.11569/wcjd.v13.i4.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
The complete and definitive treatment of patients with Mirizzi syndrome is surgical. The treatment goals are the removal of the gallbladder with the offending stone(s) and the repair of the bile duct defect. A high index of suspicion for early recognition of this condition is paramount to prevent bile duct injury. Biliary anatomy is delineated precisely by preoperative and intraoperative imaging tests. The dissection of the gallbladder is conducted in an antegrade, fundus-first fashion. Extensive dissection of Calot's triangle is avoided. Instead, the gallbladder is opened, the impacted stone(s) is removed backward, and the confirmation of the presence a cholecystocholedochal fistula is established by direct inspection. A coexistent gallbladder carcinoma is excluded by taking frozen sections. In patients without biliary fistula (Mirizzi type I), simple cholecystectomy suffices to relieve the bile duct obstruction. In patients with biliary fistula (Mirizzi type II), the size of the fistula determines the type of repair. In general, small fistulas are repaired by choledochoplasty using a cuff of gallbladder remnant, whereas large bile duct defects require bilioenteric reconstruction (Roux-en-Y hepaticojejunostomy or choledochoduodenostomy). In patients unfit for surgery, biliary decompression is effectively accomplished by placement of stents using endoscopic or percutaneous techniques. Lithotripsy and removal of the offending stone can also be carried out in patients with Mirizzi type II. In general, nonsurgical treatment of Mirizzi syndrome is incomplete and places the patients on a path of intensive follow-up, multiple procedures, and the risk to continue suffering from complications of symptomatic gallstone disease. However, nonsurgical treatment allows for valuable time to prepare high-risk patients for a more elective and safer operation.
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Affiliation(s)
- Guillermo Gomez
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
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